Editing Renal Mass and Localized Renal Cancer (2021) (section)

== Management ==

=== Counseling ===
* Discuss malignant potential based on imaging characteristics such as tumor size/complexity, histology (if available), etc.
** Low risk of mortality secondary to cT1a tumors should be described
* Discuss potential effect of intervention on risk of chronic kidney disease (CKD), dialysis, and survival.

=== Options ===
# '''Nephrectomy''' (partial vs. radical)
# '''Thermal ablation''' (radiofrequency vs. cryoablation)
# '''Active surveillance'''

==== Nephrectomy ====
*'''<span style="color:#ff0000">Partial nephrectomy</span>'''
** '''<span style="color:#ff0000">Indications</span>''' (when intervention is necessary for solid or Bosniak 3/4 complex cystic renal mass)
*** '''<span style="color:#ff0000">Absolute (3):</span>'''
***# '''<span style="color:#ff0000">Anatomic or functionally solitary kidney</span>'''
***# '''<span style="color:#ff0000">Bilateral tumors</span>'''
***# '''<span style="color:#ff0000">Known familial RCC syndrome</span>'''
*** '''<span style="color:#ff0000">Relative (6):</span>'''
***# '''<span style="color:#ff0000">cT1a renal masses (preferred over TA and RN)</span>''', not managed with active surveillance
***# '''<span style="color:#ff0000">Pre-existing CKD</span>'''
***# '''<span style="color:#ff0000">Pre-existing proteinuria</span>'''
***# '''<span style="color:#ff0000">Young age</span>'''
***# '''<span style="color:#ff0000">Multifocal masses</span>'''
***# '''<span style="color:#ff0000">Comorbidities that are likely to impact future renal function, including (4):</span>'''
***## '''<span style="color:#ff0000">Moderate to severe hypertension</span>'''
***## '''<span style="color:#ff0000">Diabetes mellitus</span>'''
***## '''<span style="color:#ff0000">Recurrent urolithiasis</span>'''
***## '''<span style="color:#ff0000">Morbid obesity</span>'''
** Surgical considerations
*** Renal function can be optimized by (2):
***# Optimizing nephron mass preservation
***# Avoiding prolonged ischemia
*** Negative surgical margins should be prioritized
**** Extent of normal parenchyma removed should consider the clinical situation and tumor characteristics, including growth pattern, and interface with normal tissue.
***** '''To optimize parenchymal mass preservation, tumor enucleation should be considered in patients with:'''
*****# '''Familial RCC syndromes'''
*****#* '''Aggressive RCC syndromes, such as HLRCC, should be best managed with wide margin PN or RN.'''
*****# '''Multifocal disease'''
*****# '''Severe CKD'''
*'''<span style="color:#ff0000">Radical nephrectomy</span>'''
** '''<span style="color:#ff0000">Indication (1)</span>''' (when intervention is necessary for solid or Bosniak 3/4 complex cystic renal mass):
**# '''<span style="color:#ff0000">If ALL criteria are met (3):</span>'''
**## '''<span style="color:#ff0000">High tumor complexity and PN would be challenging even in experienced hands</span>'''
**## '''<span style="color:#ff0000">No pre-existing CKD or proteinuria</span>'''
**## '''<span style="color:#ff0000">Normal contralateral kidney and new baseline eGFR will likely be > 45 mL/min/1.73m2 even if RN is performed</span>'''
**#* '''<span style="color:#ff0000">If ALL are not met, PN should be considered</span>''' unless there are overriding concerns about the safety or oncologic efficacy of PN.
*'''<span style="color:#ff0000">Lymphadenectomy'''
** '''<span style="color:#ff0000">Indications (1):</span>'''
**#'''<span style="color:#ff0000">Clinically concerning regional lymphadenopathy (for staging purposes)</span>'''
*'''<span style="color:#ff0000">Adrenalectomy</span>'''
** '''<span style="color:#ff0000">Indications</span>'''
***'''<span style="color:#ff0000">Absolute (1):</span>'''
***# '''<span style="color:#ff0000">If preoperative imaging or intraoperative inspection suggests metastasis or adrenal enlargement</span>'''
***#* One exception is when patient has a well-characterized adenoma, which may not mandate surgical excision
*** '''<span style="color:#ff0000">Relative (1):</span>'''
***# '''<span style="color:#ff0000">Locally advanced features are identified preoperatively or during exploration and the gland is in close proximity to the tumour</span>'''
***#* Adrenal may be spared in this setting if the contralateral adrenal gland is absent and the ipsilateral gland demonstrates normal morphology and no malignant involvement.
*Approach
** A minimally invasive approach should be considered when it would not compromise oncologic, functional, and perioperative outcomes.
*'''Other considerations'''
** Adjacent renal parenchyma in the nephrectomy specimen should be evaluated for possible intrinsic renal disease, particularly for patients with CKD or risk factors for developing CKD.
** '''Consider referral to medical oncology when there is concern for (2):'''
**# '''Metastasis'''
**# '''Incompletely resected disease'''

==== Thermal ablation (TA) ====
* '''<span style="color:#ff0000">Indications</span>'''
** '''<span style="color:#ff0000">Alternative approach for management of cT1a solid renal masses <3cm</span>'''
** Patients should be informed about the increased risk of tumor persistence or local recurrence after primary TA, compared to surgical excision, which may be treated with repeat ablation.
* Approach
**Percutaneous is preferred over surgical approach, whenever feasible, to minimize morbidity.
* Modality
** Both radiofrequency ablation and cryoablation may be offered as options
* '''Other considerations'''
**'''Biopsy should be performed prior to (preferred) or at the time of ablation''' to provide pathologic diagnosis and guide subsequent surveillance.

==== Active surveillance (AS) ====
* '''<span style="color:#ff0000">Indications'''
** '''<span style="color:#ff0000">Absolute (1):'''
**# '''<span style="color:#ff0000">Risk of intervention/competing risks of death outweighs the potential benefits of intervention'''
** '''<span style="color:#ff0000">Relative (9):'''
*** '''<span style="color:#ff0000">Tumour factors (2)'''
***# '''<span style="color:#ff0000">Solid renal mass < 2cm'''
***#*'''<span style="color:#ff0000">In patients with familial RCC syndromes, tumours can be observed if <3 cm as the risk of metastases remains low in this setting</span>'''
***#** '''<span style="color:#ff0000">HLRCC and succinate dehydrogenase deficiency RCC are the exception as tumors in these syndromes are often very aggressive.</span>'''
***# '''<span style="color:#ff0000">Complex but predominantly cystic renal masses'''
*** '''<span style="color:#ff0000">Patient factors (7)'''
***# '''<span style="color:#ff0000">Elderly'''
***# '''<span style="color:#ff0000">Life expectancy < 5 years'''
***# '''<span style="color:#ff0000">High calculated comorbidities'''
***# '''<span style="color:#ff0000">Excessive perioperative risk'''
***# '''<span style="color:#ff0000">Poor functional status'''
***# '''<span style="color:#ff0000">Marginal renal function (≥CKD3b)'''
***# '''<span style="color:#ff0000">Patient preference'''
***#* For patients who prefer AS in whom the 
***#**Risk/benefit analysis for treatment is equivocal, consider renal mass biopsy (if the mass is solid or has solid components) for further oncologic risk stratification.
***#** Anticipated benefits of intervention outweigh the risks of treatment, AS with potential for delayed intervention may be only pursued if the patient understands and is willing to accept the associated risks.
***#*** In this setting, renal mass biopsy (if the mass is predominantly solid) is encouraged for additional risk stratification.
***#*** If the patient continues to prefer AS, close clinical and cross-sectional imaging surveillance with periodic reassessment and counseling should be recommended.
* '''<span style="color:#ff0000">In patients undergoing AS, periodic clinical surveillance and/or imaging is recommended in asymptomatic patients</span>'''
** '''Frequency and intensity are tailored to patient-risk,''' based on tumour size, tumor complexity, infiltrative appearance and median growth
***'''Patients with no prior imaging should have surveillance imaging initially every 3 to 6 months'''
*** Preferred modality is not well established, but initial imaging should preferably consist of contrast-enhanced cross-sectional imaging.
*** '''Chest x-ray is warranted annually or if intervention triggers are encountered or symptoms arise.'''
* '''<span style="color:#ff0000">Indications for "intervention" (treatment or increased AS intensity) (5):</span>[https://www.auanet.org/documents/Guidelines/PDF/RCC-Active-Surveillance-Algorithm.pdf §]:'''
*# '''<span style="color:#ff0000">Tumour size >3cm</span>'''
*# '''<span style="color:#ff0000">Growth kinetics (>5mm/year)</span>'''
*#* Caution if different imaging modalities are used due to normal variations in maximal tumor diameter and volume calculations; interreader variability may also be significant.
*# '''<span style="color:#ff0000">Stage progression</span>'''
*# '''<span style="color:#ff0000">Clinical changes in patient/tumour factors</span>''' (e.g. infiltrative on imaging, suspicion of advanced T stage)
*# '''<span style="color:#ff0000">Additional biopsy results</span>''' (e.g. unfavourable histology)